Nursing Care Plan

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Medical Diagnoses: Impaired Physical Mobility, Acute pain, secondary to fractured left femur, ORIF surgery, Musculosketeal impairment

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt screams when staff attempts to move the left lower extremity.

 

Pt demonstrates difficulty with any movement of the left lower extremity.

 

 

 

 

Objective

     

Pt states that his pain level is a 9 on a 10 point pain rating scale.

 

Pt grimaces during any kind of motion or movement of his left lower extremity

     

Pt’s ORIF surgery

    


Problem:

 

Impaired Physical Mobility

Long Term:

 

Pt will be able to ambulate around the nurses’ station 2X by discharge.


* Apply any ordered brace before mobilizing the client.

     

Rationale:

“Brace support and stablilize a body part, allowing increased mobility.” (Ackley & Ladwig, 2008, p 552).

     

*Increase independence in ADLs

     

Rationale:

“Providing unnecessary assistance with transfers and activities may promote dependence and a loss of mobility.” (Ackley & Ladwig, 2008, p 552).

     

*Obtain any assistive devices needed for activity.

     

Rationale:

“Assistive devices can help increase mobility.” (Ackley & Ladwig, 2008, p 552).

X

Goal met. Pt was able to ambulate around the nurses’ station by discharge.  Pt was able to complete his activity more than twice. Pt did not complain of any pain or discomfort upon ambulation.

     

Pt states “I feel like I’m finally getting back to my old self.”

Continue interventions as listed. Encourage pt to continue the use of braces and assistive devices after discharge until he feels comfortable c/o. Encourage the pt to continue his independence in ADLs and c/o unnecessary assistance.

R/T:

    

Acute pain, secondary to fractured left femur

 

ORIF surgery

 

Anxiety

 

Musculosketeal impairment

Short Term:

 

Pt will perform passive range of motion exercises by the end of this shift.

    

*Assess the pt’s pain by using the 10 point pain rating scale q4 hrs or PRN.

 

Rationale:

“Single- item ratings of pain intensity are valid and reliable as measures of pain intensity.”

 

“The client’s report of pain is the single most reliable indicator of pain.”

 (Ackley & Ladwig, 2008, p. 604-605).

 

*Before activity, treat pain.

 

Rationale:

“Pain limits mobility and is often exacerbated by movement.” (Ackley & Ladwig, 2008, p 552).

 

X

Goal met. Pt able to fully complete passive range of motion exercises with assistance from the staff by the end of this shift. Pt did not complain of any pain associated with exercise session.


Continue interventions as listed. Continue to assess pain using the 10 point pain scale q4 hrs or PRN. Continue to provide pain control and treat as needed.

AEB

    

Grimacing during movement or activity

 

Pt complaints about pain and discomfort

 

Pt pain rating of 9 out of 10.

 

Surgery that is 2 days post-op

 

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*I = Implementation.  Check those interventions/actions/orders that were implemented.



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